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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazeiton Avenue, Stockton, California 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: v",v.sigov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFI TI <br /> Any MINOR violations noted in the 'Notice to Compiy'° in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address at <br /> the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report (IRi or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certitication and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above Noted dates will be billed <br /> at the current hourly rate. <br /> For this certification to be complete, the operator of the site must include: <br /> A statement documenting what corrective actions were taken orwill be taken for each violation <br /> Copies of sample resuitsimanifestsltraining records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: April 29, 2025 inspected By: Maria Lopez (II� <br /> Facility Address: 6421 CAPITOL AVE CERS ID: 101800-05 <br /> I certify under penalty of lawn that: <br /> 1. I have corrected the violations .specified in the Inspection Reportfrom the above-mentioned inspect€on irate. I <br /> 2. 1 have personally examined the following documentation submitted as proof of eompiiance FOR EACH VIOLATION and <br /> I believe the information to be true, accurate. and complete: <br /> Photos Paperwork Statement <br /> 3 1 am authorized to -submit this certification on behalf of the Respondent. <br /> 4 1 am aware that there are significant penalties for submitting false Information, including the possibility of a fine and/or j <br /> Imprisonment for known violations. (HSC 25191) <br /> Name: ' ' Title: '. <br /> i <br /> Date: <br /> Signature: y, L <br />